Thyroid Disease: A Post Web Exclusive

What You Need to Know About Your Body’s “Thermostat”

Millions of Americans are living with an overactive or underactive thyroid, according to the American Association of Clinical Endocrinologists (AACE). Unfortunately, many go undiagnosed until something goes terrible awry, at times wreaking havoc on one’s quality of life. In this Web exclusive interview, we offer information about diagnosing and treating thyroid disease from Dr. Jeffrey R. Garber, immediate past president of the AACE, chief of endocrinology at Harvard Vanguard Medical Associates, and associate professor of medicine at Harvard Medical School to accompany the Jul/Aug 2010 Post Investigates feature: “Thyroid: A Secret Culprit,” by Dr. Mehmet Oz.

Dr. Jeffrey GarberCourtesy AACE

Post: Who should be tested? Should it be part of a routine annual physical? Dr. Garber: Thyroid testing was not part of President Bush Sr.’s annual physical. If you remember, his hyperthyroidism was diagnosed after he had problems breathing while jogging. Today, the American Thyroid Association recommends screening every five years, starting at age 35. Universal screening is not felt to be cost effective, but most experts would recommend testing women over 60, those with symptoms, and then targeted subgroups such as smokers or those with a personal or family history that includes autoimmune conditions.

Having symptoms of thyroid disease does not mean one has it. Making a diagnosis solely based on symptoms can be inordinately difficult. However, the diagnosis becomes straightforward by testing for it. People should target themselves based on symptoms. If you are aware of thyroid conditions and believe you are experiencing enough symptoms, it is easy for a doctor to justify testing.

In addition, doctors should target patients on the basis of other risk factors. For example, I would check someone who comes to my office saying “I feel perfectly well” if I felt a lump in their thyroid or there was a compelling history. Thyroid disease is very easy to overlook.

Post: Hypothyroidism seems to be frequently in the headlines. Any reason why? Dr. Garber: I think we live in an era in which people are seeking holistic approaches—sometimes in a good sense, and sometimes in a way that they can get exploited, in my view. Thyroid disease lends itself to an approach by some practitioners that is generally symptom-based. The idea that a constellation of symptoms dictates a diagnosis, despite the lack of conventional proof, is where the tension comes in.

“What Your Doctor Won’t Tell You” is a great headline. What people don’t read about is the downside of taking thyroid hormone products. It is not a free ride. My major concern is the risk of over-treatment. The second concern is that by treating symptoms without a certain diagnosis, a doctor will overlook another important fact or condition. Hypothyroidism can masquerade as depression, but depression can masquerade as hypothyroidism, for example.

Then there is the cost of medicine and the cost of testing. I would never argue with someone who says they feel a certain way, but the data doesn’t support that treating marginal disease necessarily leads to benefit. If a person has borderline thyroid stimulating hormone (TSH) levels and no symptoms or compelling medical reason, such as planning a pregnancy, treatment may not be called for. If people are borderline and symptomatic, of course, try to treat it. But give it a limited time. Don’t just commit people to medicine and put them at risk for being over-medicated or being subject to costs and missing other possible reasons for what they are feeling. Fatigue is the 21st century complaint. We’ve got a lot of reasons to be tired besides our thyroid.

Thyroid drug analogs, or copies of thyroid hormone, are also being mentioned in the press. As recently as March 11, 2010, the New England Journal of Medicine featured a follow-up article on the subject. The concept is to design a thyroid hormone analog that has the benefits of, say, inducing weight loss or lowering cholesterol, but not the drawback of stimulating the heart.

Post: How far away is this concept from actual reality?Dr. Garber: It was pretty far away until March 11. These researchers demonstrated that one particular analog did not affect the heart, and did lower cholesterol.

Another drug analog was studied in heart disease patients. Many lost weight, but 60 percent to 70 percent of the patients dropped out of the study because they felt lousy. Since the study was not designed to analyze weight loss, researchers couldn’t do a good job of finding out whether people ate less because they had a lousy appetite, which is a terrible way to lose weight, as opposed to eating less because their appetite isn’t as high.

Post: Is there a better test for thyroid hormone levels on the horizon?Dr. Garber: Not at present. The current discussion is whether we need to take a new look at what is considered the normal range for TSH levels, depending on the situation. Data show that some TSH levels we now consider elevated—in the elderly—may not represent hypothyroidism. And, on the other hand, new guidelines are definitely going to set a lower TSH of approximately 2.5 as the upper normal in the first trimester of pregnancy.

Post: What is the link between thyroid hormone and heart attack and heart disease?Dr. Garber: If you are profoundly hypothyroid, you often become hypertensive and hypercholesterolemic. As a result, your vessels become constricted as well. Hyperthyroidism affects the heart mostly through rhythm disturbances characterized by fast heart rates including atrial fibrillation and sinus tachycardia.

Post: Are there other new developments you would like to mention?Dr. Garber: A recent discovery suggests there is a subgroup of people with a certain genotype that are more likely to feel better on a T3-T4 combination therapy. We are not at the point that we are going to start doing genetic testing on people, but the study found that certain people with a certain genotype were more likely to feel better on combination therapy. From a hot, new, and conceptual point of view, the discovery may provide yet another role for genetic testing.

Resources:

Click here for more information from the American Association of Clinical Endocrinologists and to find an endocrinologist near you.

Click here for an excerpt from “The Harvard Medical School Guide to Overcoming Thyroid Problems” by Dr. Jeffrey R. Garber, published by McGraw-Hill.

I was diagnosed with boarderline low thyroid. I had a couple of tests fine one result was 3.1 I was prescribed synthroid. But I did not take it because I ease not all the way low. That was 8 months ago. I now feel fatigued. Fogbrain. Light-headed . I have raspy voice dry skin. My hair is thinner. No appetite. Doc dsaid I vertigo. I’m wondering if I just need to take the sythroid. I’m am still working but feel out of it. My tempiture is always low. I thought raspy voice was allergies. I’m low on vitamen d and now liver enzymes are elevated. Would synthroid hurt me if I boarderline low.?

TSH regulates the release of T3 and T4, and blood tests of the master hormone can signal potential thyroid problems before symptoms appear.

“Thyroid antibody tests are of some benefit when TSH levels are borderline,” Dr. Garber continues. “Estimates of free T4 are particularly helpful when one’s thyroid status is in flux after changing thyroid medication, thyroid surgery, or radioactive iodine treatment. Total T3 and estimates of free T3 are used to diagnose overactive thyroid when T4 measures are normal. T3 testing, however, has no proven role in the diagnosis or treatment of hypothyroidism.

“Less common tests include those for TSH receptor antibodies to diagnose Graves’ disease during pregnancy (when radioactive iodine tests may not be performed) or to diagnose thyroid eye disease. Reverse T3 levels can help distinguish low thyroid hormone levels due to hypothyroidism from low thyroid hormone levels due to critical illness. Tests for alpha subunits (a component of TSH) are employed to diagnose rare pituitary disorders that cause an overactive thyroid. Determinations of thyroglobulin (a protein made by thyroid cells) and thyrocalcitonin (a hormone made by cells within the thyroid that don’t produce T3 and T4) are useful in the diagnosis and treatment of thyroid cancer.”

Dr. Garber adds that people often ask about other tests when their thyroid treatment doesn’t relieve symptoms such as depression or fatigue.

“It’s important to note that treating symptoms with higher than standard thyroid hormone [doses] increases the risk of side effects as well as the chance of overlooking other important conditions,” explains the endocrinologist.

“For example, hypothyroidism can masquerade as depression, but depression can masquerade as hypothyroidism. Likewise, there are many reasons for feeling tired besides our thyroid.”

My husband has had hypothyroid for years, his Mom died from a goiter in her thyroid @age 43; his older brother died from a heart attack (he also has hypothyroidism). He takes 300 mgm every day; but the synthroid didn’t help, he’s on a new one now still @ 300 mgm a day. He had lung problems, a pacemaker,kidney problems, etc.; most recently he had a second knee transplant. He’s doing well and is good about using his oxygen and taking his meds. We’ve been married 49 yrs this year and I don’t like to see him like this. His primary care md sent us info for contacing an endocrine system me and I pray that he will get some energy back, be less grumpy, and I am glad I found this magazine in a doctor’s office and I will follow up closely. Thank you/

Hi, I am the editor in chief of Living Life…Boomer Style Magazine and have been reading Dr. Mark Starr’s books, as well as hearing him three different times when he has been speaking publicly. His credentials are impeccable, the years he has studied the thyroid amazing as well as the doctors he has studied under. There is an easy and very inexpensive way to test for hypothyroidism–that is to take your basal temperature for six days in a row upon waking. If your body temp is low, you have hypothyroidism.

Now, this is a simplified cliff-notes version of what Dr. Mark Starr has to say, but is meant to give you an opening to this. Get his book to find out more. We will be doing an article on this in the health section of our magazine, Living Life Boomer Style, which is why the research into this.

I’m posting this comment for my wife, Mary, who is 76 years old. Her input would be almost a duplicate of the comment of Rose Williams whose comment preceded this. Mary has had numerous blood tests for a thyroid condition and they have all returned normal. Yet she still suffers from the known symptoms of hypothroidism. At present she is taking 75MCG of synthroid. I have heard from one doctor ( a psychiatrist and not her primary care doctor) that it is possible that the standard blood test may not tell the whole story. She is being treated for depression and anxiety and has been for the past seven years without any appreciable success.
My question is whether or not there are other tests to determine thyroid problems in addition to the standard blood test? Needless to say she is a very “unhappy camper”! Help would be greatly appreciated.

I have almost every symptom on the list but my doctor will only do the blood test.
I have been on thyroid mends seance 1967 and not a change.
How can I get another test when your doctor will not lessen to you.
HELP””’